NE
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A 20-year-old female is brought to the Emergency Room by her college roommate who states that the patient vomited all night. The patient complains of a sore throat and says she has not eaten for the last two days. She admits to a "sugar problem" and quit taking her medication because she has not been eating. Examination reveals an ill-appearing woman. Her temperature is 37.9 C (100.2 F), blood pressure is 118/78 mm Hg, pulse is 160/min, and respirations are 30/min. The patient's lips and mucous membranes are dry. There is a fruity odor noted to the patient's breath. The lung and cardiac examination are unremarkable except for mild tachypnea and tachycardia. Laboratory analysis shows:
Sodium......................130 mEq/L
Potassium..................6.1 mEq/L
Chloride....................100 mEq/L
Bicarbonate...............8 mEq/L
Urea nitrogen............10 mg/dL
Creatinine.................1.0 mg/dL
Glucose....................680 mg/dL
pH...........................7.15
pCO2.......................30 mm Hg
pO2.........................85 mm Hg
Urinalysis is positive for ketones.
Which of the following is the most appropriate initial step in management?
A. Immediate intubation
B. Intravenous insulin
C. Intramuscular ceftriaxone
D. IV fluid bolus with normal saline and potassium
E. Mannitol
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| damngood
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B iv insulin
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| munnabhai MRCS
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d
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| doyoudig
Forum Guru
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well she is not hypotensive n her K is still high (shuld not be gievn unless it drops to < 4.5)
BBBBB
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| Luckyall
Forum Guru
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mmmmm.... i dont think we should give her more Potassium bc is already > 5mEq/L though i would hydrate her with .9%NaCl since she s been vomiting alll night, dry lips& mucousmebranes (excluding D)
No Manitol bc she s not having cerebral edema
IS either ( A)immediate intubation----> bc of possible URI 
OR (B)IV insulin
i go for A
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| sprint123
Forum Guru
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Potassium is not given unless the level is normal or decreased.
I go for B-IV insulin!
I think intubation is not needed due to only mild tachypnea!
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| Justice
Forum Fanatic
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Posts: 2,324
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I remember a tense discussion of this Q a while ago...
While this Pt does require fluids first, the option D contain potassium, which is not needed at the beginning... later, when you normalize Pt's sugar and blood potassium (so, the answer is B) with IV insulin (it is still will be in some volume of normal saline so the fluids will be given first), then you add potassium to the treatment.
So, the answer is B
(B)
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| NE
Forum Guru
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The patient has hyperglycemic coma- first step in management after ABC- INSULIN. If we would suspect hyperosmolar coma the first step should be fluid with K despite normal serum K because would be "false" normopotasemia.
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